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SUMMARY OF BENEFITS

INTERNATIONAL STUDENT

INDIVIDUAL COVERAGE

Welcome! This is a short-term medical Plan intended to provide Accident and Illness coverage while you are

temporarily away from your Home Country and studying abroad.

Please keep this Summary of Benefits as an explanation of the benefits available to You under the contract between

the Insurer and the Policyholder. This Summary of Benefits is not a contract between You and the Insurer. The Master

Policy is on file with the Policyholder and contains all of the provisions, limitations, exclusions, and qualifications of

Your insurance benefits, some of which may not be included in this Summary of Benefits.

While you are temporarily residing in the United States, there are requirements and instructions on how to maximize

benefits and receive reimbursements for Prescription Medications, medical claims, and other benefits covered under

this Plan. There are also requirements for Pre-Authorization of specified medical care. Dedicated GBG Assist

personnel are available to assist you.

• Using an In-Network medical Provider in the U.S results in lower out-of-pocket costs to you. See the

section titled “Preferred Provider Network” for assistance with locating a Provider.

• Pre-Authorization is a process for obtaining approval for specified non-emergency, medical procedures

or treatments. Failure to Pre-Authorize when required will result in a reduction in payment by the Insurer. See

the section titled, “Pre-Authorization Requirements and Procedures” for more complete details.

• Prescription Medication must be obtained from a CVS/Caremark pharmacy. Present your Medical

Identification card to the pharmacist and a discount will be applied. Payment is due at the time of purchase.

• Hospital Emergency Rooms should only be used in Medical Emergency situations. A Medical Emergency

situation is where your life or health is in jeopardy. Using an emergency room is very expensive. If you are using

an emergency room for convenience or for any reason other than a Medical Emergency, you will be responsible

for a large portion of the payment.

How You Can Reach Us

Customer Service, Pre-Authorization, and Help Locating a Provider (24/7)

➢ Worldwide Collect +1.786.814.4125

➢ Inside USA/Canada Toll Free +1.866.914.5333

➢ Email: [email protected]

➢ Website: www.gbg.com

We invite you to visit our Member Services Portal at www.gbg.com and register as a New Member. The Member

Services Portal allows you to conveniently access our Provider directory, download forms, submit claims, and utilize

other valuable tools and services.

We look forward to providing you with this valuable insurance protection and outstanding service during your

period of study.

THANK YOU FOR SELECTING

GLOBAL BENEFITS GROUP

STUDENT HEALTH INSURANCE

Table of Contents

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SCHEDULE OF BENEFITS

The Schedule of Benefits is a summary outline of the benefits covered under this insurance Plan. The benefits are

divided into three sections; Medical Expense Benefits, Non-Medical Expense Benefits, and Accidental Death &

Dismemberment Benefits. Please read the Description of Benefits sections for full details. All benefits described are

subject to the definitions, exclusions and provisions.

ELIGIBLE PERSONS

Eligible Person is an individual who meets all the requirements of one of the covered Classes shown below:

Class 1

• A registered Full Time Undergraduate or a Graduate Student attending classes who is a minimum age of 16

years and maximum of 40 years;

• Student must have a current passport and be travelling outside their Home Country; and

• Student must have a valid F, H, M, O, or Q visa. F1 visa holder on OPT are not eligible.

Class 2

• The spouse or domestic partner of a Class 1 Insured Person

Class 3

• The Dependent child(ren) of a Class 1 Insured Person

MEDICAL EXPENSE BENEFITS

The following Medical Expense Benefits are subject to the Insured Person’s Deductible, Copayment, and Coinsurance

amount. After satisfaction of the Deductible and applicable Copayments, the Insurer will pay eligible benefits set

forth in this Schedule at the specified Plan Coinsurance and reimbursement level.

GENERAL FEATURES AND PLAN SPECIFICATIONS

U.S. Provider Network Aetna

Area of Coverage United States and Home Country

Home Country Coverage per Period of Insurance $1,000

Maximum Benefit Payable per Period of Insurance Unlimited

Lifetime Maximum Unlimited

Individual Deductible per Period of Insurance1

• In-Network Provider

• Out-of-Network Provider

$500 (2x individual per family)

$750 (2x individual per family

1 The Deductible for In-Network does not accrue towards the Out-of-Network Deductible.

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Office Visit Copayment2

(waived at Student Health Center) $25

Urgent Care Center Copayment2 $50

Emergency Room Copayment2

(waived if admitted) $150 per Occurrence

Out-of-Pocket-Maximum3

$6,350 In-Network per Insured Person

(excluding Deductible)

Unlimited if an Out-of-Network Provider

in the U.S. is used

Pre-Existing Condition Limitation

(12 month Lookback Period)

Student: Pre-Existing conditions are covered

without a Waiting Period

Dependents: Pre-Existing conditions are

covered after a 24 month Waiting Period

Note: All Deductibles and Copayments will be waived when treatment is rendered at the Student Health Center.

Benefits will be paid at the In-Network Coinsurance percentage, subject to Usual, Customary and Reasonable

charges.

COVERED SERVICES AND BENEFIT LEVELS

Subject to Deductible, Coinsurance, Copayment, and

Maximum Benefit per Period of Insurance.

WHAT THE INSURANCE PLAN COVERS

The following Coinsurance applies for In-Network Providers in

the U.S. or for expenses incurred outside the U.S. (if available).

Coinsurance reduces to 70% UCR when Out-of-Network

Providers in the U.S. are used.

HOSPITALIZATION AND INPATIENT BENEFITS

Accommodations including semi-private room 80% Preferred Allowance

Intensive Care/Cardiac Care 80% Preferred Allowance

Inpatient Consultation by a Physician or Specialist 80% Preferred Allowance

Hospital Miscellaneous Expense 80% Preferred Allowance

Pre-Admission Testing 80% Preferred Allowance

Extended Care/Skilled Nursing Facility/Inpatient

Rehabilitation

• Maximum Benefit per Period of Insurance: 45 days

• Must be confined to facility immediately following a

Hospital stay

80% Preferred Allowance

OUTPATIENT BENEFITS

Physician Visit/Consultation by Specialist

• $25 Copayment Physician/Specialist

• $50 Copayment Urgent Care Center


2 Copayments do not apply to the Deductible or the Out-of-Pocket Maximum. 3 The Deductible does not apply to the Out-of-Pocket Maximum.

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Diagnostic Testing

• X-Ray and Laboratory

• MRI, PET, and CT Scans

• Office visit Copayment applies when testing is done

outside an office visit


Therapeutic Services, Physical Therapy, Chiropractic,

Occupational Therapy, Vocational and Speech

Therapy

• Maximum Benefit : 12 visits per covered Illness/Injury

• Office visit Copayment applies


SURGICAL BENEFITS (INPATIENT/OUTPATIENT)

Inpatient, Outpatient or Ambulatory Surgery

Includes:

• Surgeon’s Fees

• Out-of-Network Assistant Surgeon or

Anesthesiologist (up to 25% of Usual, Customary &

Reasonable for surgery)

• Facility fees

• Laboratory tests

• Medications and dressings

• Other medical services and supplies


EMERGENCIES

Emergency Room and Medical Services

• $150 Copayment (waived if admitted)

• 70% Coinsurance for non-emergency use


Ambulance Services

• Emergency local ground ambulance 80% Preferred Allowance

Emergency Dental

• Limited to accidental Injury of sound natural teeth

sustained while covered

• Maximum Benefit per Period of Insurance: $1,000


up to $250 per tooth

MATERNITY CARE

Normal delivery or Medically Necessary C-Section, pre-

natal, post-natal care, and Complications of Pregnancy 80% Preferred Allowance

Elective Abortion

• Maximum Benefit per Period of Insurance: $1,500 80% Preferred Allowance

OTHER BENEFITS (INPATIENT/OUTPATIENT)

Inpatient Mental Health

• To treat a covered diagnosis 80% Preferred Allowance

Outpatient Mental Health

• Office visit Copayment applies 80% Preferred Allowance

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Preventive Care and Annual Exams

• 0-12 months: 9 visits maximum

• Child/Adult: Annual exams, immunizations

• In-Network or Student Health Center only


(Student Health Center payable at UCR)

Palliative Dental Care

• Sudden onset of pain

• Maximum Benefit per Period of Insurance: $600


Alternative Medicine (Homeopathic Care and

Acupuncture)

• Maximum Benefit per Period of Insurance: $500

• Office visit Copayment applies


Chemotherapy, Radiotherapy 80% Preferred Allowance

Home Health Agency Care 80% Preferred Allowance

Hospice Care

• Inpatient Maximum Benefit per Period of Insurance:

45 Days

• Outpatient Maximum Benefit per Period of Insurance:

$5,000


OTHER BENEFITS (INPATIENT/OUTPATIENT) (CONTINUED)

Diabetic Medical Supplies

• Includes Insulin Pumps and associated supplies

• Maximum Benefit per Period of Insurance: $7,500

80% UCR

Acquired Immunodeficiency Syndrome (AIDS)

Human Immunodeficiency Virus (HIV+), AIDS Related

Complex (ARC), Sexually transmitted diseases and all

related conditions


Durable Medical Equipment

• Reimbursement of rental up to the purchase price 80% UCR

Alcohol and Substance Abuse

• Rehabilitative treatment only

• Outpatient office visit Copayment applies


Prescription Medications

• Up to 31-day supply per prescription

• Includes contraceptives

• CVS/Caremark network pharmacy is required

$10 Copayment per prescription for Tier 1



Motor Vehicle Accident

• Injuries caused by Accident 80% Preferred Allowance

Sports and Other Activities

• Injuries arising from Interscholastic, Intramural, and

Club Sports


Passive War and Terrorism Included

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NON-MEDICAL EXPENSE BENEFITS

Non-Medical Expense Benefits do not accumulate towards the Medical Expense Maximum Benefit payable per

Period of Insurance or toward the Lifetime Maximum.

ADDITIONAL BENEFITS

Compassionate Care Visit

• Maximum Benefit per Period of Insurance: $2,500 100%

Return of Minor Children

• Maximum Benefit per Period of Insurance: $2,500 100%

Medical Evacuation and Repatriation 100%

Return of Mortal Remains 100%

ACCIDENTAL DEATH AND DISMEMBERMENT

ACCIDENTAL DEATH AND DISMEMBERMENT

Principal Sum for Primary Insured Person $30,000

Time Period for Loss 90 days from the date of the covered Accident

Loss of: Benefit: Percentage of Principal Sum

Accidental Death 100%

Loss of Both Hands or Feet, or Loss of Entire Sight of Both

Eyes 100%

Loss of One Hand and One Foot 100%

Loss of One Hand or Foot and Entire Sight of One Eye 100%

Loss of One Hand or Foot 50%

Loss of Sight of One Eye 50%

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1.0 GENERAL PROVISIONS

The Policyholder is the International Benefit Trust, hereinafter shall be referred to as the “Trust”.

The Insurer, AXIS Specialty Europe SE, hereinafter shall be referred to, sometimes collectively, as the “Insurer”, “We”

“Us”, or “Company”.

The declarations of the Insured Person in the application serve as the basis for participation in the Trust. If any

information is incorrect or incomplete, or if any information has been omitted, the insurance coverage may be

rescinded or terminated. Any references in this Summary of Benefits to the Insured Person are expressed in the

masculine gender shall be interpreted as including the feminine gender whenever appropriate.

No change may be made to this Summary of Benefits unless it is approved by an Officer of the Insurer. A change

will be valid only if made by a Rider signed by an Officer of the Insurer. No agent or other person may change this

Summary of Benefits or waiver any of its provisions.

This Plan is an international health insurance Policy issued to the Trust. This insurance shall be governed by the Laws

of England and Wales and subject to the non-exclusive Jurisdiction of the courts of England and Wales, and the

Insured Person should be aware that laws governing the terms, conditions, benefits and limitations in health

insurance policies issued and delivered in other countries including the United States are not applicable. If any

dispute arises as to the interpretation of this document, the English version shall be deemed to be conclusive and

taking precedence over any other language version of this document.

Notwithstanding any other terms under this Plan, the Insurer shall not provide coverage nor make any payments or

provide any service or benefit to any Insured Person, beneficiary, or third party who may have any rights under this

plan to the extent that such cover, payment, service, benefit or any business activity of the Insured Person would

violate any applicable trade or economic sanctions, law or regulation.

2.0 ELIGIBILITY

2.1 Eligible Classes International full-time students (as defined by the educational institution) enrolled in an associate, bachelor, master,

or Ph.D. program at a university or other recognized higher education institution outside of their Home Country.

The full-time requirement is waived for summer if the student was enrolled in this Plan as a full-time student in the

immediately preceding spring term. Home study, correspondence, and online courses do not fulfill the eligibility

requirements that the student actively attend class.

Students must actively attend classes. The Insurer has the right to investigate eligibility status and attendance

records to verify eligibility requirements are met. If it is discovered the eligibility requirements are not met, the

insurance coverage will be terminated.

2.2 Persons Eligible to be an Insured Person The Insured Person on this policy who is an Eligible Person as identified in the Schedule of Benefits, a Non-United

States Citizen travelling outside their Home Country and travelling to the United States and has their true, fixed and

permanent home and principal establishment outside of the United States and holds a current and valid passport,

and for whom proper Premium payment has been made when due.

Insured Persons are those persons described as an Eligible Class.

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Students who are United States citizens are not eligible for coverage.

2.3 Eligible Dependents Coverage can be extended to the following family members who are traveling with the student who is the Insured

Person. Insured Dependents may include:

• The spouse or domestic partner up to age 40,

• Dependent children up to age 26, if single. Dependent children include the Insured Person’s natural children,

legally adopted children, and stepchildren.

Dependents who are United States citizens are not eligible for coverage.

2.4 Application and Effective Date The Insured Person’s coverage becomes effective on the Effective Date shown on the Medical Identification Card.

Coverage under the Plan ends on the earlier of:

• On the expiration date of the insurance coverage. However, if an Insured Person’s return is delayed due to

unforeseeable circumstances beyond their control, the insurance coverage will be extended until such trip

can be completed, but no later than seven days from the original insurance coverage expiration, or

• If medical evacuation was necessary, upon the Insured Person’s evacuation to the Home Country.

• Termination of coverage of the Insured Person also terminates coverage for Dependents.

Note: The minimum period of insurance must be the entire duration the Insured Person actively attends classes.

2.5 Pre-Existing Conditions Limitations For Plans that include a Waiting Period for Pre-Existing Conditions, the Waiting Period will be reduced by the total

number of months that the Insured Person provides documentation of continuous coverage under prior Creditable

Coverage which provided benefits similar to this Plan provided the coverage was continuous to a date within 63

days prior to the Insured Person’s Effective Date.

2.6 Addition of a Newborn Baby or Legally Adopted Child Born Under a Pregnancy Covered by the Maternity Benefit or Adopted as of the Date of Birth:

Newborn babies will be covered as a Dependent, for full coverage according to the terms of the Policy, regardless

of medical status from the date of birth provided:

• Written notification is made to the Insurer within 31 days of the date of birth, or in the case of an adopted

child, a copy of the legal adoption papers is required. The newborn child shall be accepted from the date

of birth

• The newborn baby will be enrolled for the same coverage as the Insured Person.

Any request received beyond the 31-day notification period shall result in coverage only being effective from the

date of notification and provisional coverage will be applied for the first 31 days of life, up to a $5,000 maximum.

Coverage is not guaranteed and is subject to submission of a medical statement.

Born When an Insured Person is Not Covered by the Maternity Benefit: Newborn babies, that are born, and the

Insured Person is not covered by the maternity benefit under this Plan, may be covered subject to the following:

• The Insured Person will provide written notification to the Insurer (Official Copy of Birth Certificate), and

• A Health Statement must be submitted detailing the medical history of the child,

• Coverage will become effective as of the date of notification, provided the Insurer has approved the Health

Statement, Coverage is not guaranteed and is based upon the health of the newborn baby,

• Any applicable Pre-existing condition limitation will apply.

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2.7 Addition of a Legally Adopted Child After the Date of Birth A child adopted after the date of birth may be covered providing the following applies:

• The child must be up to 19 years old, and

• The Insured Person will provide written notification to the Insurer (an official copy of the legal adoption

papers is required with the notification), and

• A Health Statement must be submitted detailing the medical history of the child.

Coverage will be contingent based upon the terms and conditions of the Plan. Additionally,

• Coverage will become effective as of the date of notification, and

• Any applicable Pre-Existing Condition limitation will apply.

2.8 Extended Coverage The Extended Coverage benefit is available to newly enrolled students who arrive in the United States prior to the

beginning of the first term of study in the United States, or Insured Persons who have completed their final term of

study in the United States and are preparing to return to the Home Country. The Extended Coverage benefit

provides up to 30 days of additional coverage.

Extended Coverage does not apply to Insured Persons who are continuing their studies or returning to studies in

the United States whether at the same or different institutions.

Newly-Enrolled and Arriving Students

In order to be eligible for the Extended Coverage Benefit and before any benefits will be paid:

1. A newly-enrolled and arriving student must have enrolled in full-time Studies at the higher education

institution, and

2. All Premiums must be paid.

Coverage under the Extended Coverage Benefit will become effective on the later of:

1. 30 days prior to the beginning of the term, or, if later,

2. On the first day the qualifying, newly-enrolled and arriving student arrives in the United States.

Students Concluding their Studies

An Insured Person may extend coverage for a maximum of 30 days while remaining in the United States following

graduation or completion of an educational program. To be eligible for the Extended Coverage benefit and before

any benefits will be paid:

1. The Insurer must receive the request for Extended Coverage prior to the termination of the Insured Person’s

coverage, and

2. All Premiums must be paid.

Coverage under the Extended Coverage Benefit will terminate on the earlier of:

1. 30 days following the Insured Person’s graduation or completion of an educational program, or

2. The date of departure from the United States.

Dependents of Insured Persons who are covered under the Extended Coverage benefit may also continue coverage

under the same terms and conditions as the Insured Person.

Extended Coverage for Short-Term Programs

In the event the Insured Person’s entire program of study is less than 60 days, the applicable Extended Coverage

benefit will be limited to seven days. All other Extended Coverage benefit provisions will apply as indicated herein.

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3.0 PREMIUM, CANCELLATION, AND POLICY PROVISIONS

3.1 Premium Payment All Premiums are payable before coverage is provided, unless otherwise agreed upon.

3.2 Cancellation The Insurer may at any time terminate an Insured Person, or modify coverage to different terms, if the Insured

Person has at any time:

• Misled the Insurer by misstatement or concealment;

• Knowingly claimed benefits for any purpose other than are provided for under this Plan;

• Agreed to any attempt by a third party to obtain an unreasonable pecuniary advantage to the Insurer’s

detriment;

• Failed to observe the terms and conditions of this Plan or failed to act with utmost good faith.

If the Insured Person cancels the insurance coverage after it has been issued or reinstated, the Insurer will only

refund Premium on a pro rata basis if the Insured Person provides proof of other health coverage or other valid

reason for cancellation as determined by the Company or its Administrator. Premium refunds will not be considered

if a claim has been filed during the Period of Insurance.

3.3 Period of Insurance The insurance coverage term begins on the Effective Date as shown on the Medical Identification Card and ends at

midnight on the date shown, but no longer than 365 days later. The coverage is not subject to guaranteed issuance

or renewal.

3.4 Duration of Coverage Benefits are paid to the extent that a Insured Person receives any of the treatments covered under the Schedule of

Benefits following the Effective Date, including any additional Waiting Periods and up to the date such individual

no longer meets the definition of Insured Person, or their last date of coverage.

3.5 Compliance with the Plan Terms The Insurer’s liability to an Insured Person will be conditional upon that Insured Person complying with its terms

and conditions.

3.6 Fraudulent/Unfounded Claims If any claim is in any respect fraudulent or unfounded, all benefits paid and/or payable in relation to that claim shall

be forfeited and, if appropriate, recoverable.

3.7 Waiver of Terms or Conditions The waiver of a term or condition by the Insurer in relation to an individual case will not prevent the Insurer from

relying on such term or condition thereafter.

3.8 Denial of Liability Neither the Insurer nor the Policyholder is responsible for the quality of care received from any institution or

individual. This insurance coverage does not give the Insured Person any claim, right or cause of action against the

Insurer or Policyholder based on an act of omission or commission of a Hospital, Physician or other Provider of care

or service.

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3.9 Extension of Benefits If an Insured Person is Hospital confined on the termination date of coverage, benefits will continue to be paid until

the earlier of: discharge from the Hospital they are confined to, or until the Maximum Benefit has been paid,

whichever occurs first. In no event will benefits continue beyond 30 days from the termination date of coverage.

3.10 Preferred Provider Network The Insurer maintains a Preferred Provider Network both within and outside the United States.

United States only:

• In-Network Preferred Provider: This tier consists of all Providers as well as other Preferred Providers

designated by the Insurer and listed on the website. In-Network Providers have agreed to accept a

Preferred Allowance as payment in full. The Medical Identification Card contains the logo for the network.

Present it to the Physician or Hospital.

• Out-of-Network Provider: Utilizing Providers that are Out-of-Network is a more costly financial option for

the Insured Person. The Insurer reimburses such Providers up to an Allowable Charge as determined by the

Insurer. The Provider may bill the Insured Person the difference between the amounts reimbursed by the

Insurer and the Provider’s billed charge. Additionally, the Insured Person will pay a Coinsurance amount

that is higher than if an In-Network Provider were used.

• Out-of-Network Area: When there are no network Providers located within a 30-mile radius of your local

residence, charges from such Providers will be treated the same as a U.S. In-Network Preferred Provider.

The Insurer retains the right to limit or prohibit the use of Providers which significantly exceed Allowable Charges.

4.0 PRE-AUTHORIZATION REQUIREMENTS AND PROCEDURES

Pre-Authorization is a process by which a Insured Person obtains approval for certain medical procedures or

treatments prior to the commencement of the proposed medical treatment. This requires the submission of a

completed Pre-Authorization Request form to GBG Assist a minimum of five business days prior to the scheduled

procedure or treatment date.

The following services require Pre-Authorization:

• Any Hospitalization;

• Outpatient or Ambulatory Surgery;

• All Cancer Treatment (Including Chemotherapy and Radiation);

• Prescription medications in excess of $3,000 per refill; and

• Medical Evacuation/Repatriation and all other Non-Medical Expense benefits;

• Any condition, which does not meet the above criteria, but are expected to accumulate over $10,000 of

medical treatment per Period of Insurance.

Either you, your doctor, or your representative must call the number listed on the back of the Medical Identification

Card to obtain Pre-Authorization and verification of Network utilization. Prior to the performance of services, a letter

of authorization will be provided.

Medical Emergency Pre-Authorizations must be received no later than 48 hours after the Admission or procedure.

In instances of an emergency, you should go to the nearest Hospital or Provider for assistance even if that Hospital

or Provider is not part of the Network.

Failure to obtain pre-authorization will result in a 30% reduction in payment of covered expenses. Any such penalty

will apply to the entire episode of care and does not apply to the Out-of-Pocket maximum. If treatment would not

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have been approved by the pre-authorization process, all related claims will be denied.

Pre-Authorization approval does not guarantee payment of a claim in full, as additional Copayments and Out-of-

Pocket expenses may apply. Benefits payable under the Plan are still subject to eligibility at the time charges are

actually incurred, and to all other terms, limitations, and exclusions of the Plan.

In the event of an emergency that requires medical evacuation, contact GBG Assist in advance in order to approve

and arrange such emergency medical air transportation. GBG Assist, on behalf of the Insurer, retains the right to

decide the medical facility to which the Insured Person shall be transported. Approved medical evacuations will

only be to the nearest medical facility capable of providing the necessary medical treatment. If the person chooses

not to be treated at the facility and location arranged by GBG Assist, then transportation expenses shall be the

responsibility of the Insured Person. Failure to arrange transportation as indicated will result in non-payment of

transportation costs.

5.0 MEDICAL EXPENSE BENEFIT DESCRIPTIONS

THE FOLLOWING PROVIDES AN EXPLANATION OF THE BENEFITS OFFERED BY THE INSURER. PLEASE REFER

TO THE SCHEDULE OF BENEFITS FOR THE SPECIFIC BENEFITS COVERED UNDER THIS PLAN OF INSURANCE.

All benefits provided under this Policy for a covered Illness or Injury must be:

• Ordered or recommended by a Physician and under the scope of the Physician’s licensing;

• Medically necessary; and

• Delivered in an appropriate medical setting.

5.1 HOSPITALIZATION AND INPATIENT BENEFITS

5.1.a Accommodations Benefits are provided for room and board, special diets, and general nursing care. All charges more than the

allowable semi-private room rate are the responsibility of the Insured.

Benefits are also provided for treatment in the Intensive Care or Coronary Care Unit if it is the most appropriate

place for the Insured to be treated, the care provided is an essential part of the Insureds treatment, and the care

provided is routinely required by patients suffering from the same type of Illness or Injury or receiving the same

type of treatment.

The Insurer will pay costs if:

Treatment is Medically Necessary for the Insured Person to be treated on an Inpatient or Daycare basis,

The stay in the Hospital is for a medically appropriate period of time, and

The treatment received is provided or managed by a Physician or specialist

Not Covered Under this Benefit

Inpatient Hospital Confinements primarily for purposes of receiving non-acute, long term Custodial Care, respite

care, chronic maintenance care, or assistance with Activities of Daily Living (ADL), are not eligible expenses.

Expense for items that are provided solely for personal comfort or convenience such as television, private rooms,

housekeeping services, guest meals and accommodations, special diets, telephone charges, and take-home supplies

are not covered.

5.1.b Medical Treatment, medicines, laboratory, diagnostic tests, and ancillary services Benefits are provided for Medically Necessary diagnosis and treatment of the Illness or Injury for which a Insured

Person is Hospitalized, the following services are also covered:

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• Blood transfusions, blood plasma, blood plasma expanders, and all related testing, components, equipment

and services,

• Laboratory testing,

• Durable Medical Equipment,

• Diagnostic X-ray examinations,

• Radiation therapy,

• Respiratory therapy, and

• Chemotherapy.

5.1.c Inpatient Consultation by a Physician or Specialist Benefits are provided for the reimbursement of one Physician visit per day while the Insured Person is a patient in

a Hospital or approved Extended Care Facility. Visits that are part of normal preoperative and postoperative care

are covered under the surgical fee and Insurer will not pay separate charges for such care. If Medically Necessary,

the Insurer may elect to pay more than one visit of different Physicians on the same day if the Physicians are of

different specialties. The Insurer will require submission of records and other documentation of the Medical

Necessity for the intensive services.

5.1.d Extended Care, Skilled Nursing Facility, and Inpatient Rehabilitation Benefits are provided for an Inpatient Confinement and services provided in an approved extended care facility

following, or in lieu of, an Admission to a Hospital as a result of a covered Illness or Injury. Care provided must be

at a skilled level and is payable in accordance with the current Schedule of Benefits. Coverage for Confinement is

subject to Insurer approval. Covered services include the following:

• Skilled nursing and related services on an Inpatient basis for patients who require medical or nursing care

for a covered Illness. A Confinement includes all approved extended care facility Admissions not separated

by at least 180 days.

• Rehabilitation for patients who require such care because of a covered Illness, disability or Injury.


Intermediate, custodial, rest and homelike care services will not be considered skilled and are not covered.

5.2 OUTPATIENT BENEFITS

5.2.a Physician Visits Benefits are provided for medical visits to a Physician, in the Physician’s office, if Medically Necessary. Benefits are

limited to one visit per day per Insured Person. The Insurer may elect to pay more than one visit to different

Physicians on the same day if the Physicians are of different specialties.

5.2.b Outpatient Diagnostic Testing Benefits are provided for diagnostic testing including echocardiography, ultrasound, MRI, and other specialized

testing, to diagnose an Illness or Injury.

5.2.c Therapeutic Services Benefits are provided for Medically Necessary therapeutic services rendered to a Insured Person as an Outpatient

of a Hospital or Provider’s office. Services must be pursuant to a Physician’s written treatment Plan, which contains

short- and long-term treatment goals and is provided to Insurer for review. The following services must either:

• Produce significant improvement in the Insured Person’s condition in a reasonable and predictable period

of time; and

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• Be of such a level of complexity and sophistication, and the condition of the patient must be such that the

required therapy can safely and effectively be performed; or

• Be necessary to the establishment of an effective maintenance program.

5.3 SURGICAL BENEFITS

5.3.a Surgical Services Benefits are provided for covered surgical services received in a Hospital or a Physician’s office. Surgical services

include: use of operation room and recovery room, operative and cutting-procedures, treatment of fractures and

dislocations, surgical dressings, and other Medically Necessary services.

5.3.b Anesthesia Services Benefits are provided for the service of an anesthesiologist, other than the operating surgeon or assistant, who

administers anesthesia for a covered surgical or obstetrical procedure.

5.3.c Reconstructive Surgery Benefits are provided for reconstructive surgery as a result of an Accident or Illness will be covered as long as it is

determined that it is Medically Necessary.

5.4 EMERGENCIES

5.4.a Emergency Room Benefits are provided for a Medical Emergency when incurred in a Hospital’s emergency room. The Insurer retains

the right to deem a true Medical Emergency. Admission to the Hospital is not required for benefit consideration.

Within the United States, use of the emergency room for non-emergency services may result in higher Out-of-

Pocket costs to the Insured Person.

5.4.b Emergency Ground Ambulance Services Benefits are provided for Medically Necessary emergency ground ambulance transportation to the nearest Hospital

able to provide the required level of care.


The use of ambulance services for the convenience of the Insured Person will not be considered a covered service.

5.4.c Emergency Dental Benefits are provided for Emergency Dental treatment and restoration of sound natural teeth required as a result of

an Accident. All treatment must begin within 72 hours of the Accident.


Routine dental treatment is not covered under this benefit.

5.5 MATERNITY CARE

The following maternity benefits are covered and are applicable to any condition related to pregnancy, including but

not limited to childbirth, prenatal, miscarriage, premature birth, and Complications of Pregnancy. For a pregnancy

related to a Dependent spouse, conception must occur at least 10- months after the Effective Date for the pregnancy

to be covered. Fertility/infertility services including but not limited to tests, treatments, medications, and/or procedures,

complications of that pregnancy, delivery, postpartum care, and care or treatment for an individual acting as a

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surrogate including delivery of the child are excluded from coverage. The following benefits are only available to the

primary Insured Person or Spouse. No benefits are available for a Dependent Child.

5.5.a Physician and Obstetrical Services Benefits are provided for the following maternity related benefits:

• Obstetrical and other services rendered in a licensed Hospital or approved birthing center, including

anesthesia, delivery, Medically Necessary C-section, prenatal and postnatal care for any condition related

to pregnancy, including but not limited to childbirth and miscarriage;

• All prenatal and postnatal Physician’s office visits, laboratory and diagnostic testing; and

• Prenatal vitamins are covered during the term of the pregnancy only, if prescribed by a Physician.


Elective C-sections are not covered.

5.5.b Newborn Infant Care Services Benefits are provided for Hospital nursery services and medical care provided by the attending Physician for

newborn infants in the Hospital are covered. Charges for Hospital nursery services and professional services for the

newborn infant are covered separately from the mother’s Maternity benefits and are subject to satisfaction of the

Individual Deductible and Coinsurance.

5.5.c Complications of Pregnancy and Congenital Conditions Benefits are provided for health complications as a result of a pregnancy and are subject to the Maximum Benefit

per Period of Insurance and not the Maximum Benefit under Maternity.

5.6 OTHER BENEFITS (INPATIENT/OUTPATIENT)

5.6.a Mental Health Benefits Benefits are provided for both Inpatient mental health treatment in a Hospital or approved facility and for Outpatient

mental health treatment. A Physician, licensed clinical psychologist, social worker, or licensed professional counselor

must provide all mental health care services. Treatment must be provided for a psychiatric disease identified in the

most recent edition of the American Psychiatric Association Diagnostic and Statistical Manual or the International

Classification of Diseases.


Non-medical counseling services including but not limited to addictive behavior counseling, marriage and family

counseling, educational counseling, aptitude testing, educational testing and services are not covered under this

benefit.

5.6.b Preventive Care Child Wellness: Benefits are provided for well-child routine medical exams, health history, development

assessments, immunizations, and age-related diagnostic tests covered up to the age of 12-months.

Adult Wellness: Benefits are provided for routine physical examinations, immunizations for infectious diseases as

recommended by the Center for Disease Control and preventive medical attention.

Adult Female Screenings

The following exams are included.

• Routine Mammogram

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o Ages 35-39: One baseline exam

o Ages 40-49: One exam every one or two years

o Age 50 and beyond: One exam annually

o Any Age: When Necessary

• Papanicolaou (PAP) Screening: One exam annually

Adult Male Screenings

The following exams are included.

• PSA Screening Test: Ages 50 and older, one test annually

5.6.c Palliative Dental Care Benefits are provided for emergency pain relief treatment to natural teeth or gums for an eligible palliative dental

condition. Benefits are payable in accordance with the Schedule of Benefits.

5.6.d Alternative Medicine Benefits are provided for the following:

• Acupuncture and Homeopathy where such is provided as treatment for an Illness covered under this Plan;

• Treatment is covered only by certified Acupuncture and Homeopathy specialists.

5.6.e Home Health Agency Care including Nursing Services Benefits are provided for Home Nursing and other Home Health Care services. Nursing care is defined as prescribed

care that can only be provided by a licensed Registered Nurse (RN) or Licensed Practical Nurse (LPN) which is

Medically Necessary to treat identified medical conditions on a temporary, limited basis. These services need to

meet specified medical criteria to be covered. Home nursing is provided immediately following treatment as an

Inpatient on Physician recommendation. Home nursing is not provided solely for the convenience of the family

caregiver.


Intermediate, custodial, rest and homelike care services will not be considered skilled and are not covered

5.6.f Hospice Hospice is a program approved by Insurer to provide a centrally administered program of palliative and supportive

services to terminally ill persons and their families. Terminally ill refers to the patient having a prognosis of 240 days

or less. Covered services are available in home, Outpatient and Inpatient settings. The Hospice care guidelines are:

• Must relate to a medical condition that has been the subject of a prior valid claim with the Insurer, with a

diagnosis of terminal Illness from a medical doctor;

• Benefit is payable only in relation to care received by a recognized hospice.

5.6.g Diabetic Medical Supplies Benefits are provided for certain diabetic supplies including insulin pumps and associated supplies.

5.6.h HIV/AIDS Benefits are provided for Medically Necessary, non-Experimental services, supplies and medications for the

treatment of Acquired Immunodeficiency Syndrome (AIDS), Human Immunodeficiency Virus (HIV +), AIDS Related

Complex (ARC), sexually transmitted diseases and all related conditions.

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5.6.i Durable Medical Equipment Benefits are provided for items which are designed for and able to withstand repeated use by more than one person

and customarily serve a medical purpose. Such equipment includes but is not limited to, wheelchairs, Hospital beds,

respirators, and dialysis machines. Such Durable Medical Equipment (DME) must be:

• Prescribed by a Physician,

• Customarily and generally useful to a person only during an Illness or Injury,

• Equipment must be appropriate for use in the home and are not disposable, and

• Determined by the Insurer to be Medically Necessary and appropriate.

Allowable rental fee of the Durable Medical Equipment must not exceed the purchase price. Charges for repairs or

replacement of artificial devices or other Durable Medical Equipment originally obtained under this Plan will be paid

at 50% of the allowable reasonable and customary amount.


Some items not covered under Durable Medical Equipment include but are not limited to the following:

• Comfort items such as telephone arms and over bed tables, or

• Items used to alter air quality or temperature such as air conditioners, humidifiers, dehumidifiers, and

purifiers, or

• Miscellaneous items such as exercise equipment, heat lamps, heating pads, toilet seats, bathtub seats, or

• The customizing of any vehicle, bathroom facility, or residential facility.

High performance devices for sports or improvement of athletic performance, and power enhancement or power-

controlled devices, nerve stimulators, and other such enhancements are not covered. Limbs and other devices

intended to replace the functionality of the body part being replaced and the repair and replacement of such devices

are not covered.

5.6.j Alcohol and Substance Abuse Benefits are provided for Inpatient and Outpatient services including diagnosis, counseling, and other medical

treatment rendered in a Physician's office or by an Outpatient treatment department of a Hospital, community

mental health facility or alcoholism treatment facility, so long as the facility is approved by the Joint Commission on

the Accreditation of Hospitals or certified by the Department of Health. The services must be legally performed by

or under the clinical supervision of a licensed Physician or a licensed psychologist who certifies that the Insured

Person needs to continue such treatment.

5.6.k Prescription Medications Benefits are provided for medications which are prescribed by a Physician and which would not be available without

such Prescription.


Certain treatments and medications, such as vitamins, herbs, aspirin, cold remedies, medicines, Experimental and/or

Investigational medications, or supplies, even when recommended by a Physician, do not qualify as Prescription

Medications. Any medication that is not scientifically or medically recognized for a specific diagnosis or that is

considered as off label use, Experimental, or not generally accepted for use will not covered, even if a Physician

prescribes it.

5.6.l Motor Vehicle Benefits are provided for injuries sustained in a motor vehicle accident in accordance with the benefits shown in the

Schedule of Benefits.

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5.6.m Passive War and Terrorism This Plan covers bodily Injury directly or indirectly caused by, or resulting from certain acts of War and Terrorism,

provided the Insured Person is not an active participant, or in training for in such activities. This benefit considers

the following activities acts of War and Terrorism, excluding the use of nuclear, chemical, or biological weapons of

mass destruction.

1. War, hostilities or warlike operations (whether war be declared or not),

2. Invasion,

3. Act of an enemy foreign to the nationality of the Insured Person or the country in, or over, which the act

occurs,

4. Civil war, Riot, Rebellion, Overthrow of the legally constituted government,

5. Military or usurped power,

6. Explosions of war weapons,

7. Murder or Assault subsequently proved beyond reasonable doubt to have been the act of agents of a state

foreign to the nationality of the Insured Person whether war be declared with that state or not,

8. Terrorist activity.

6.0 NON-MEDICAL EXPENSE BENEFIT DESCRIPTIONS

ALL NON-MEDICAL EXPENSE BENEFITS MUST BE ARRANGED THROUGH GBG ASSIST. FAILURE TO DO SO

WILL RESULT IN NON-PAYMENT OF BENEFITS. PLEASE CONTACT GBG ASSIST IN ADVANCE IN ORDER TO

FACILITATE ADMINISTRATION OF THESE BENEFITS.

6.1 Compassionate Care Visit The Insurer will reimburse travel costs to repatriate the Insured Person to their Home Country in the event there is

a serious life-threatening Illness, Injury, or death of a spouse, domestic partner, parent, parent-in-law, child,

grandchild, brother, sister of fiancé. The family member must be a resident in the Home Country of the Insured

Person. Travel costs include economy round-trip airfare to the Home Country with a return to the Insured Person’s

country of study. In all cases, the decision rest solely with the insurance company’s medical representatives who will

make the final and binding determination. In the event of death, a certificate of death must be provided.

6.2 Return of Minor Children In the event an Insured Person’s minor children under the age of 18 are present but left unattended as a result of

the Insured Person’s Injury or Illness, the Insurer will coordinate economy class, one-way airfare to return the children

to the Insured Person’s Home Country. Transportation expenses and accommodations of a non-medical escort are

included, if required.

6.3 Medical Evacuation/Repatriation In the event of an Emergency that requires medical evacuation, contact GBG Assist in advance in order to approve

and arrange such emergency medical air transportation. GBG Assist, on behalf of the Insurer, retains the right to

decide the medical facility to which the Insured Person shall be transported. Approved medical evacuations will only

be to the nearest medical facility capable of providing the necessary medical treatment. If the Insured Person

chooses not to be treated at the facility and location arranged by GBG Assist, then transportation expenses shall be

the responsibility of the Insured Person. Failure to arrange transportation as indicated will result in non-payment of

transportation costs. The cost of a person accompanying a Insured Person is covered under this Policy, with expenses

subject to pre-approval by GBG Assist.

Sea and Offshore Evacuation: If an Insured Person is Injured or becomes ill at sea (i.e cruises, yachting, etc.), the

Insurer will not consider any benefit until the Insured Person is on land. This means any costs involved from an

22 | P a g e

evacuation from sea to land will not be considered under this Plan. Once on land, this Plan will cover medical costs

and further evacuation, according to the insurance coverage and terms. If a Insured Person is at sea, the Insurer

would request the Insured Persons are evacuated by sea rescue to a country within their purchased Area of

Coverage, where circumstances allow.

Medical Repatriation: If an Insured Person can no longer meet the Eligibility requirements due to medical reasons,

GBG Assist and the Insured’s attending Physician will make the determination if Medical Repatriation to the Home

Country is necessary. GBG Assist will coordinate return to the Home Country. If the Insured Person refuses

Repatriation, the Plan will be terminated for failure to meet Eligibility requirements.

6.4 Return of Mortal Remains A benefit for either Repatriation of mortal remains, or Local Burial is included. This benefit excludes fees for return

of personal effects, religious or secular memorial services, clergymen, flowers, music, announcements, guest

expenses and similar personal burial preferences. The necessary clearances for the return of an Insured Person’s

mortal remains by air transport to the Home Country will be coordinated by GBG Assist.

7.0 ACCIDENTAL DEATH AND DISMEMBERMENT BENEFIT DESCRIPTION

The Insured Person must receive initial medical treatment within 30 days of the date of Accident. The maximum

amount payable for this benefit is the Principal Sum indicated on the Schedule of Benefits. If the Insured Person

incurs a covered loss, the Insurer will pay the percentage of the Principal Sum shown in the table on the Schedule

of Benefits. If the Insured Person sustains more than one such loss as the result of one Accident, the Insurer will

only pay one amount, the largest to what the Insured Person is entitled. Except for Accidental Death, the loss must

result within 90 days of the Accident. Your coverage under the Plan must be in force.

For purposes of this benefit:

• Loss of a Hand or Foot means complete severance through or above the wrist or ankle joint.

• Loss of Use of a Hand or Foot means total loss of all ability to move the hand or foot, within 365 days of a

Covered Accident, that continues for 6 months and is expected to continue for the remainder of the Insured

Person's lifetime.

• Loss of Sight means the total, permanent loss of sight of the eye. The loss of sight must be irrecoverable

by natural, surgical or artificial means.

• Severance means the complete separation and dismemberment of the part from the body.

8.0 EXCLUSIONS AND LIMITATIONS

Sanctions Limitation Clause

The Insurer will not provide any cover, pay any claim or provide any benefit under this Policy to the extent that the

provision of such cover, the payment of such claim or the provision of such benefit would expose them to any

sanction, prohibition or restriction under United Nations resolutions or the trade or economic sanctions, laws or

regulations of the European Union, United Kingdom or United States of America.

8.1 Medical Expense Benefits Exclusions and Limitations All services and benefits described below, including expenses for medical treatment not expressly indicated in the

Medical Expense Benefit section, are either excluded from coverage or limited under this Plan of Insurance.

1. Aircraft Travel: Travel in any aircraft owned, leased operated or controlled by the Policyholder, or any of its

subsidiaries or affiliates. An aircraft will be deemed to be “controlled” by the Policyholder if the aircraft may be

used as the Policyholder wishes for more than 10 straight days, or more than 15 days in any year.

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2. Alcohol and Substance Abuse, Secondary Illness/Injury: Treatment of any Illness or Injury caused by,

contributed to, or resulting from voluntary use of alcohol, illegal substance abuse, drug, poison, gas or fume, or

any medication that is not taken in the dosage or for the purpose prescribed. The operating of any type of

vehicle or conveyance while under the influence of alcohol or any of the above listed substances including

prescribed drugs for which the Insured was provided a written warning against operating a vehicle or

conveyance while taking it. Under the influence of alcohol, for purposes of this exclusion, means intoxicated, as

defined by the motor vehicle laws of the state in which the Covered Loss occurred.

3. Breast reduction: All services and treatments.

4. Charges Reimbursable by Another Entity: Services, supplies, or treatment that are provided by or payment is

available from: a) Workers’ Compensation law, occupational disease law or similar law concerning job related

conditions of any country; or; b) Another insurance company or government; or c) A government entity due to

an epidemic or public emergency; d) Services provided normally without charge by the Health Services Center

of the institution attended by the Insured Person, or services covered or provided by a student health fee.

5. Cosmetic and Elective Surgery for Non-Medical Reasons: Treatments, procedures or medications which are

primarily for enhancement, improvement, or altering one’s appearance, unless required due to a non-

occupational Injury occurring while insured under this Plan. Medical complications arising from such treatments

or procedures are also not covered.

6. Dental Care: Except for Accidental injury to sound, natural teeth.

7. Experimental or Off-Label Services: Services, supplies or treatments, including medications, which are

deemed to be Experimental or Investigational or that is not medically recognized for a specific diagnosis.

8. Fertility/Infertility Treatments and Birth Control: Any services, procedure or treatment including medications

used to: a) Treat infertility including In-vitro Fertilization (IVF), Gamete Intrafallopian Transfer (GIFT), Zygote

Intrafallopian Transfer (ZIFT), and any variations of these procedures, and any costs associated with the

preparation or storage of sperm for artificial insemination. b) Vasectomies and sterilization, and any expenses

for male or female reversal of sterilization.

9. Genetic Screening: Counseling, screening, testing, or treatment in the absence of any symptoms or any

significant, proven risk factors for genetically linked inheritable disease.

10. Hearing Care: Hearing exams, hearing aids or devices, unless due to an Injury/Illness covered under the Policy.

Surgical implantation of, or removal of bone anchored hearing devices and cochlear implants.

11. Home Country and Care Outside the U. S.: a) All medical charges incurred in the Insured Person’s Home

Country, in excess of the amount shown on the Schedule of Benefits. b) All medical charges incurred outside

the U.S.

12. Illegal Activities: Injuries or Illnesses resulting or arising from or occurring during the commission of an assault

or felony.

13. Immunizations for Travel: Vaccines and preventive medications recommended or required for travel to

specific countries.

14. Medical Examinations or Certificates: Any examination, immunization, or tests necessary for the issuance of

medical certificates or determining employment, or suitability for school, sport related activities, or travel or

determining insurability.

15. Motor Vehicle: Medical expenses resulting from a motor vehicle Accident if the Insured Person is the operator

of a motor vehicle and does not possess a valid motor vehicle operator’s license, unless: (a) the Insured Person

holds a valid learners permit and (b) the Insured Person is receiving instruction from a driver’s education

instructor.

16. Nasal Surgery: Deviated septum, submucous resection and/or other surgical correction thereof, nasal and sinus

surgery except for treatment of a covered Injury.

17. Non-Medical Care: Services related to Custodial Care, respite care, home-like care, assistance with Activities of

Daily Living (ADL), or Milieu Therapy. Any Admission to a nursing home, home for the aged, long term care

facility, sanitarium, spa, hydro clinic, or similar facilities. Any Admission arranged wholly or partly for domestic

reasons, where the Hospital effectively becomes or could be treated as the Insured Person’s home or permanent

abode.

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18. Organ Transplant: Organ transplant and related procedures and expenses.

19. Podiatric Care: Routine foot care, including the paring and removing of corns, calluses, or other lesions, or

trimming of nails or other such services not resulting from an Illness or Injury. Orthopedic shoes or other

supportive devices such as; arch supports, orthotic devices, or any other preventative services or supplies to

treat the diagnosis of weak, strained, or flat feet or fallen arches.

20. Prescription Medications: Prescription Medications, services or supplies as follows:

a) Therapeutic devices or appliances, including: support garments and other non-medical substances,

regardless of intended use, except as specifically provided in this Plan, b) Immunization agents, except as

specially provided, biological sera, blood or blood products administered on an Outpatient basis, c) Refills in

excess of the number specified or dispensed after one year of the date of the prescription, d) Growth hormones,

e) Medications used to treat or cure baldness or thinning hair.

21. Sexual Dysfunction: Any procedures, supplies, or medications used to treat male or female sexual

enhancement or sexual dysfunction such as erectile dysfunction, premature ejaculation, and other similar

conditions.

22. Skin Conditions: Acne, rosacea, skin tags, and any other treatment to enhance the appearance of the skin,

except for cystic or pustular acne.

23. Sleep Studies: Sleep studies and other treatments relating to sleep apnea.

24. Smoking Cessation: Treatments and other expenses, whether or not recommended by a Physician.

25. Sports and Hazardous Activities: a) Participation, practice, or conditioning program for any Intercollegiate or

professional sport or competition, including cheerleading, or travelling to/from such sport or competition as a

participant; b) Skydiving, parachuting, SCUBA diving (deeper than 30 meters), mountain climbing (where ropes

or guides are used), bungee jumping, skiing (off groomed trails), snowboarding, racing by any animal or motor

vehicle, motorcycling, spelunking, whitewater rafting (level 4 and higher), hang gliding, glider flying, parasailing,

or flight in any kind of aircraft (except as a passenger in a regularly scheduled flight of a commercial airline) c)

Power Vehicles: Expenses for Accidents or Injuries as a result of motorcycles, mopeds, scooters, ATV’s, any one,

two, or three wheeled motorized vehicle and/or sport watercraft such as wave runners, jet skis, or other powered

devices whether the vehicle is in motion or not.;

26. Transsexual Surgery: Medical or psychological counseling, hormonal therapy in preparation for, or subsequent

to, any such surgery, surgical procedures, and any other expenses related to sexual reassignment including the

complications arising from such procedures.

27. Vision Care: Expenses including examinations, eye refractions, frames, lenses, contact lenses, fitting of frames

or lenses, or vision correction surgery.

28. War and Terrorism: a) Any loss sustained while participating in, or training for, or as a consequence of war

(declared or not), or warlike operations; b) voluntary, active participation in a riot or insurrection; c) Terrorist

activity including the use of armaments, the detonation of any form of explosive or nuclear devices, the emission,

discharge, dispersal, release or escape of any solid, liquid or gaseous Chemical agent and/or Biological agent,

including the poisoning via the air or water supplies or food products and deliberate destruction of buildings

and transportation. This exclusion extends to any action taken in controlling, preventing, suppressing or in any

way relating to any terrorist activity; d) Ionizing radiations or contamination by radioactivity from any nuclear

fuel or from any nuclear waste from the combustion of nuclear fuel, or the radioactive, toxic, explosive or other

hazardous properties of any explosive nuclear assembly or nuclear component thereof.

29. Weight Related Treatment: Any expense, service, or treatment for obesity, weight control, any form of food

supplement, weight reduction programs, dietary counseling, or surgical procedures related to morbid or non-

morbid obesity. Charges relating to complications arising from such treatments or surgical procedures are also

excluded.

30. Services or treatment rendered by any person who is: a) living in the Insured Person’s household, b) an

Immediate Family Member of either the Insured Person or the Insured Person’s spouse, or c) the Insured Person.

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8.2 Non-Medical Expense Benefits Exclusions and Limitations The Insurer shall not be responsible for providing the following non-medical expense benefits to an Insured Person

in a situation arising from or in connection with any of the following.

1. Travel costs that were neither arranged or approved in advance by the Insurer or authorized vendor or affiliate.

2. Taking part in military or police operations.

3. Insured Person’s failure to properly procure or maintain visa, permits, or other documents.

4. The actual or threatened use or release of any nuclear, chemical, or biological weapon or device, or exposure

to nuclear reaction or radiation, regardless of the contributory cause.

5. Any evacuation or Repatriation that requires an Insured Person to be transported in a biohazard-isolation unit.

6. Medical evacuation from a marine vessel, ship, or watercraft of any kind.

7. Medical evacuation directly or indirectly related to a natural disaster.

8. Subsequent medical evacuations for the same or related Illness, Injury, or emergency medical evacuation

event regardless of location.

8.3 Accidental Death & Dismemberment Exclusions and Limitations The losses shown below or expenses resulting from or in connection with any of the following are excluded from

coverage under this Policy.

1. Illegal Activities: Losses resulting or arising from or occurring during the commission of an assault or felony.

2. Kidnap and Hijacking: Any loss caused directly or indirectly from kidnap or wrongful detention of the Insured or hijacking of any aircraft, motor vehicle, train or waterborne vessel on which the Insured Person is travelling.

3. Professional Sports: Any loss sustained while participating in or training for any sport or activity performed for

financial gain.

4. Self-Inflicted Illnesses, Injuries, or Exceptional Danger: a) Treatment for any conditions as a result of self-

inflicted Illnesses or injuries, suicide or attempted suicide, while sane or insane. b) Treatment for any loss or

expense of nature directly or indirectly arising out of, contributed to, caused by, resulting from, or in connection

with self-exposure to peril or bodily Injury, except in an endeavor to save human life.

5. Sports and Hazardous Activities: Losses resulting from a) Participation, practice, or conditioning program for

any Interscholastic, Intercollegiate, or professional sport or competition, or travelling to/from such sport or

competition as a participant; b) Skydiving, parachuting, SCUBA diving (deeper than 30 meters), mountain

climbing (where ropes or guides are used), bungee jumping, skiing (off groomed trails), snowboarding, racing

by any animal or motor vehicle, spelunking, whitewater rafting (level 4 and higher), hang gliding, glider flying,

parasailing, or flight in any kind of aircraft (except as a passenger in a regularly scheduled flight of a commercial

airline) ) c) Power Vehicles: Expenses for Accidents or Injuries as a result of motorcycles, mopeds, scooters, ATV’s,

any one, two, or three wheeled motorized vehicle and/or sport watercraft such as wave runners, jet skis, or other

powered devices whether the vehicle is in motion or not.;

6. Substance Abuse: Any loss directly or indirectly resulting from alcohol or illegal drug abuse or other addiction,

or any drugs or medicines that are not taken in the dosage or for the purpose prescribed.

7. War and Terrorism: a) Any loss sustained while participating in, or training for, or as a consequence of war

(declared or not), or warlike operations. b) voluntary, active participation in a riot or insurrection c) Terrorist

activity including the use of armaments, the detonation of any form of explosive or nuclear devices, the emission,

discharge, dispersal, release or escape of any solid, liquid or gaseous Chemical agent and/or Biological agent,

including the poisoning via the air or water supplies or food products and deliberate destruction of buildings

and transportation. This exclusion extends to any action taken in controlling, preventing, suppressing or in any

way relating to any terrorist activity. d) Ionizing radiations or contamination by radioactivity from any nuclear

fuel or from any nuclear waste from the combustion of nuclear fuel, or the radioactive, toxic, explosive or other

hazardous properties of any explosive nuclear assembly or nuclear component thereof.

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9.0 HOW TO FILE A CLAIM

Claims must be filed within 180 days of treatment to be eligible for reimbursement of covered expenses. Claim

forms should be submitted only when the medical service Provider does not bill the Insurer directly, and when you

have out-of-pocket expenses to submit for reimbursement. All claims worldwide are subject to Usual, Customary,

and Reasonable charges as determined by GBG and are processed in the order in which they are received. In order

for claims payment to be made, claims must be submitted in a form acceptable to Insurer.

9.1 Medical Claims To file your claim, submit it online at www.gbg.com. Log into the Member Area and select Submit Claim, and then

follow the instructions to complete the online claim form. If you are unable to submit your claim electronically, you

can mail or fax your completed claim form and copies of supporting documentation. After submitting the claim,

you will receive a claim reference number and an electronic receipt for the claim will be sent to you by email.

Claims may be submitted to the Insurer directly by the Provider or Facility. The Insurer will process the claim

according to the Schedule of Benefits and Plan terms, and remit payment to the health care Provider. Ineligible

charges or those in excess of the Allowable Charges will be the responsibility of the Insured Person.

If the Insured Person has paid the health care Provider, the Insured Person will submit the claim form along with the

original paid receipts directly to the Insurer. Photocopies will not be accepted unless the Claim is submitted

electronically. The Insurer will reimburse the Insured Person directly according to the Schedule of Benefits and Plan

terms.

9.2 Accidental Death and Dismemberment Claims To substantiate a claim for benefits covered by the terms of this Plan, the following initial documents must be

submitted:

• An official certificate of death, indicating date of birth of the Insured Person;

• A detailed medical report at the onset and course of the disease, bodily Injury or Accident that resulted in

the death or dismemberment. In the event of no medical treatment, a medical or official certificate stating

the cause and circumstances of death;

• The Insurer will pay the benefit as soon as the validity of the claim for benefits has been reasonably satisfied.

Expenses incurred in relation to the substantiation of a claim will not be the responsibility of the Insurer.

Submit claims by:

Web: Mail: Fax: Email:

www.gbg.com

GBG Administrative Services

7600 Corporate Center Drive, Suite

500

Miami, FL 33126 USA

+1 949 271 2330

[email protected]

9.3 Reimbursement Options Claims reimbursements will be made by:

Electronic Direct Deposit for the Insured Person where the receiving bank is located in the U.S.,

Wire Transfer for the Insured Person’s and overseas Providers where the receiving bank is located outside

of the U.S., or

Check sent to the Insured Person or Provider where electronic payment is not possible.

9.4 Settlement of Claims When claims are presented to the Insurer, the Allowable Charges will be applied towards the Deductible. Once the

27 | P a g e

Deductible has been satisfied, all Allowable Charges will be paid at the percentage listed on the Schedule of Benefits,

up to the listed benefit maximum. Note the amount of Allowable Charges applied towards the Deductible also

reduces the applicable benefit maximum by the same amount.

If the Plan has an Out-of-Pocket Maximum, once it is met the Plan will begin paying 100% of Allowable Charges for

the remainder of insurance coverage, subject to the benefit maximums. The Out-of-Pocket Maximum does not apply

to any expenses covered under the Prescription Medications benefit.

9.5 Status of Claims Insured Person’s wishing to request the status of a claim or have a question about a reimbursement received, please

submit the status request form via our website at www.gbg.com or e-mail customer service at

[email protected]. Inquiries regarding the status of past claims must be received within 12 months of the

date of service to be considered for review.

9.6 Releasing Necessary Information It may be necessary for the Insurer to request a complete medical file on a Insured Person for purpose of claims

review or administration of the Plan. It may also be necessary to share such information with a medical or utilization

review board, or a reinsurer. The release of such confidential medial information will only be with written consent

of the Insured Person.

9.7 Coordination of Benefits It is the duty of the Insured Person to inform Insurer of all other coverage. In no event will more than 100% of the

Allowable Charge and/or Maximum Benefit for the covered services be paid or reimbursed. If a Insured Person has

coverage under another insurance contract, including but not limited to health insurance, worker’s compensation

insurance, automobile insurance (whether direct or third party), occupational disease coverage, and a service

received is covered by such contracts, benefits will be reduced under this Plan to avoid duplication of benefits

available under the other contract. This includes benefits that would have been payable had the Insured Person

claimed for them.

Note: if Primary coverage is also a PPO, the lesser of the two contracted rates will be the Allowable Charge.

9.8 Subrogation When the Plan pays for expenses that were either the result of the alleged negligence, or which arise out of any

claim or cause of action which may accrue against any third party responsible for Injury or death to the Insured

Person by reason of their eligibility for benefits under the Plan, the Plan has a right to equitable restitution.

9.9 Appeals Procedure If a claim is wholly or partially denied, a written notice will be sent to the Insured Person containing the reason for

the denial. The notice will include a reference to the provision in the Plan description and a description of any

additional information which might be necessary for reconsideration of the claim. The notice will also describe the

right to appeal. A written appeal, along with any additional information or comments, may be sent within 6 months

after notice of denial. In preparing the appeal, the Insured Person, or their representative, may review all documents

related to the claim and submit written comments and issues related to the denial. After the written notice is filed

and all relevant information is presented, the claim will be reviewed, and a final decision sent within 60 days after

receipt of the notice of the appeal. Under special circumstances, an extension for further review will be granted, but

not for longer than 60 additional days.

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10.0 COMPLAINTS PROCEDURE

GBG is committed to providing Insured’s with an exceptional level of service and customer care. Sometimes things

can go wrong or there may be occasions when the service provided to you was not adequate. When this happens,

please contact GBG and give us the opportunity to correct the situation and earn back your trust.

Who to Contact?

The most important factors in getting Your complaint dealt with as quickly and efficiently as possible are:

• Be sure You are talking to the right person; and

• That You are providing the necessary information.

When You Contact Us

Please provide the following information:

• Your name, telephone number, and email address;

• Your policy and/or claim number and the plan of benefits (medical, travel, disability) You are insured for;

and

• Please explain clearly and concisely the reason for Your complaint.

Step One: Making a Complaint

If Your complaint relates to:

1. The sale of the policy You purchased or any information You were given during the sales process:

a. If You purchased the policy using a broker or other intermediary, please contact them first.

b. If You purchased the policy directly from Us either from a local representative, using the website, or

through a group plan of benefits, please contact Us directly at:

Toll Free

+1.866.914.5333

(within the U.S. and Canada)

Phone

+1.786.814.4125

(outside the U.S. and Canada)

Email

[email protected]

c. You may also submit Your complaint via Our Complaint Form, which may be accessed by visiting Our

website and navigating to the Forms page: www.gbg.com/#/oursolutions/forms.

2. A claim for benefits, the terms and conditions of the policy, or other benefit related information:

a. Complaints related to a claim denial should be submitted as soon as possible. We will review the

information and provide a response within four weeks or will request additional time, if needed.

b. Claims and benefits related complaints should be referred to Our Complaints Department:

Toll Free

+1. 877.916.7920

(within the U.S. and Canada)

Phone

+1. 949.916.7941

(outside the U.S. and Canada)

Email

[email protected]

c. You may also submit Your complaint via Our Appeal Form, which may be accessed by visiting Our

website and navigating to the Forms page: www.gbg.com/#/oursolutions/forms.

We always aim to resolve Your complaint and provide a final response within four weeks, but if it looks like it will

take Us longer than this, We will let You know the reasons for the delay and inform You of the options available to

You.

mailto:[email protected]://www.gbg.com/#/oursolutions/formsmailto:[email protected]://www.gbg.com/#/oursolutions/forms

29 | P a g e

Step Two: Beyond Your Insurer

If Your complaint is not resolved in the appropriate timeframe or if You are unhappy with Our final response, You

may be eligible to refer Your complaint to an alternative dispute resolution body. The details of the appropriate

body will be provided on request or as required.

Alternatively, if your Home Country is a member of the European Economic Area (EEA) You may be eligible to submit

Your complaint to the Online Dispute Resolution (ODR) Platform set up by the European Commission. This service

has been set up to help consumers who have bought goods or services online get their complaint resolved. You can

access the ODR Platform at

11.0 COMPENSATION

This section of Your Plan is only applicable if Your Home Country IS a member of the European Economic

Area (EEA)

In the unlikely event that the Insurer is unable to pay its share of any claim under this Policy, You may be entitled to

compensation from an insurance compensation fund.

Details of the fund will be provided on request or as required (where applicable).

12.0 LAW AND JURISDICTION

This insurance is governed by the laws of England and Wales and subject to the non-exclusive jurisdiction of the

courts of England and Wales. Any laws governing the terms, conditions, benefits and limitations in health insurance

policies issued and delivered in other countries are not applicable.

13.0 FAIR PROCESSING NOTICE

Purpose and Scope of this Notice

This notice is intended to explain how your personal information (personal data) will be handled by AXIS Specialty

Europe SE ("AXIS", "we", "our" or "us") of Mount Herbert Court, 34 Upper Mount Street, Dublin 2, Ireland. AXIS

values its relationship with you. Protecting the privacy of your personal information is of great importance to us.

We want you to understand what personal information we collect from you, how and why we collect such

information about you, how we use it, your rights regarding this information, the conditions under which we may

disclose it to others and how we keep it.

This notice applies to you because you have taken out international student health insurance coverage and have

been issued with a summary of benefits ("Certificate of Coverage" or "Coverage") through the policyholder,

International Benefits Trust ("Policyholder"). For the purposes of your Certificate of Coverage, Global Benefits

Europe B.V. ("GBE") is an appointed agent who acts on behalf of us. Your Coverage is underwritten by AXIS.

What type of information do we obtain about you?

The personal information we obtain about you may include:

• Name, address, phone number, email

• Gender

• Marital status

• Date and place of birth

• Government identification numbers - National Insurance, Social Security, passport, tax, driver’s license

• Banking information – account and credit card details

https://nam12.safelinks.protection.outlook.com/?url=https%3A%2F%2Furldefense.com%2Fv3%2F__http%3A%2F%2Fwww.ec.europa.eu%2Fconsumers%2Fodr__%3B!!GFfiRA!_9LmdCNHMwtBDCTdhRMPqGlUEA1UqgqNHowMbnZ4J5Lj41wUUnh3ZVEVpOAhxFPMRzqn%24&data=02%7C01%7C%7Cd753da8acdc24192424a08d7fdaf9378%7Cb29a8edc93e94c0193b3b877b686b138%7C0%7C0%7C637256802864455576&sdata=4xiB80PtZ8Qn0%2BTElWfWwujTElGgTAReMz07Vkmf6RA%3D&reserved=0

30 | P a g e

• Coverage benefits (medical, travel, disability)

• Visa information

• Family information – spouse/co-habiting partner, dependent(s)/child(ren)

• Health information / medical history

• Travel history/information

• Claims/Coverage numbers

Please note that, in the context of claims, we may ask for further or different types of personal information depending

on the claim. For example, your travel arrangements and your location at the time your claim arose.

How do we obtain information about you?

We obtain personal information about you from the Policyholder in the following instances:

• When you take out your Coverage: we underwrite your Coverage in conjunction with our appointed agent, GBE.

Your Certificate of Coverage is held by the Policyholder for your benefit

• When you bring a claim pursuant to the terms of your Coverage: we manage any claims that you bring under

your Coverage. To manage your claims, we engage with our claims handler, GBG Administrative Services, Inc

("GBGAS"), who oversees the claims handling process on our behalf.

We may also collect or obtain information about you from your family members, credit reference agencies, anti-

fraud databases, sanctions lists, relevant government agencies, and those who may be involved in a claim –

claimants, witnesses, experts, adjusters, and others.

Where you provide personal information to us other than your own (via our appointed agent, GBE), you confirm

that you will explain to the person(s) in question that you have provided his/ personal information to us (via our

appointed agent, GBE) and that he/she understands that his/her personal information will be processed in line with

this notice.

Why do we obtain your personal information?

We may collect your personal information for the following purposes:

• Account setup, including background checks

• Evaluating risks to be covered

• Customer service communications

• Payments to/from individuals

• Managing insurance or reinsurance claims

• Defending or prosecuting legal claims

• Investigating or prosecuting fraud

• Complying with legal or regulatory obligations.

What is the legal basis for us obtaining your personal information?

When we process your personal information, we do so on the following grounds:

• To perform the terms of your Coverage

• To pursue our legitimate interests: to train our staff in how to perform their duties/our services, to improve our

service, to carry out statistical analysis, to enhance our product offerings and to assist in regulatory inquiries.

Before processing your personal information to pursue our legitimate interests, we carefully assess the impact

of our processing activities on your rights and freedoms. On balance, we consider that our legitimate interests

do not override your rights and freedoms which require the protection of your personal information

• To comply with laws or regulations to which we are subject

• To exercise, establish or defend legal claims or proceedings to which you may be a party.

31 | P a g e

When we process special categories of your personal information (e.g. health information), we do so on the

following grounds:

• For the purposes of your Coverage, where it is necessary and proportionate, subject to suitable and specific

measures being taken to protect your personal information

• To exercise, establish or defend legal claims or proceedings to which you are or may be a party.

Who receives your personal information?

We will share your personal information with various representatives of AXIS along with our appointed agent, (GBE)

and, claims handler (GBGAS) affiliates, reinsurers, agents or contractors.

Where does your information go?

If you are ordinarily resident in the European Economic Area (EEA), you should be aware that we will need to transfer

your personal information to som

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